Program Integrity Investigative Coordinator I

Job Summary:

The Program Integrity Investigative Coordinator I monitors and maintains all SIU fraud reporting mechanisms (hotline, facets routing, fax, emails) to ensure compliance with regulatory requirements.

Essential Functions:

• Accurately load Fraud, Waste & Abuse (FWA) referrals into the SIU Case Management System
• Analyze FWA allegation facts and evaluate whether cases can be closed or escalated
• Interview claimants, providers, members or any other individuals to obtain information relevant to any FWA investigation
• Review claims for irregular billing patterns, consulting specialists when necessary
• Generate various reports utilizing multiple fraud detection software systems
• Conduct rudimentary data analysis to determine financial exposure or risk to FWA allegation across all lines of business
• Responsible for maintaining anonymity and confidentiality during all phases of intake process
• Independently identify billing errors and accidental overpayments initiating corrective action through the Research and Resolution Submission portal
• Request medical records on an as-needed basis and as directed by Team Lead; partner with Clinical staff to resolve any issues
• Assist Program Integrity in the oversight of Delegated Entities by routing state directed correspondence and generating claims data reports across all lines of business
• Prepare and document Attestations, De-conflictions and Additional Allegation FWA informational letters, as contractually required, for any state Medicaid agency
• Attend state Medicaid investigative meetings to transcribe updates provided by the Attorney General’s Office; update any applicable cases
• Support compliance and regulatory requirements by verifying all state/federal directed provider removals are completed accurately across all lines of business
• Drive accuracy of database information maintained in Case Management System; proactively verify the accuracy of provider information in concert with Facets and the Medicaid Information Technology System
• Know and uphold the provisions of the Corporate Compliance Plan
• Perform any other job related instructions as requested

Education and Experience:

• High School Diploma or GED is required
• Associate’s Degree in Health-Related Field, Law Enforcement, or Insurance is preferred
• Minimum of three (3) years’ experience in a health care related field or Customer Service is required
• Health care experience preferred (medical/dental claims, auditing, medical office experience, etc.)

Competencies, Knowledge and Skills:

• Intermediate computer skills consisting of Microsoft Excel, Access, Outlook, Word, and Power Point
• Ability to navigate multiple software systems at a high proficiency level
• Good communication skills
• Ability to work independently and within a team environment
• High attention to detail
• Critical listening and thinking skills
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Strong organization skills
• Customer service oriented

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

Originally posted on Himalayas